Eating Disorders

Tiffany L. Bell, D.O.

Department of Psychiatry

The Ohio State University

College of Medicine

With Special Thanks to Amanda M Pedrick, MD

PGY-1, Psychiatry, The OSU Wexner Medical Center for her amazing efforts in narration and annotations.

Learning Objectives

Recognize distinguishing characteristics of patients with anorexia and bulimia.

Why We Need to Know:

Eating disorder prevalence is estimated at 3-7% in teenagers

Disorders of eating exist across a continuum Those who develop eating disorders during

adolescence may die or live with the sequela Obesity has become an epidemic in the 21st

century Dieting (and fear of fatness) is associated with

the development of eating disorders

Historical Overview

William Hammond published the first review of patients with anorexia in 1879.

Patients with this syndrome were described throughout the middle ages.

Cultural obsession with thinness & weight in women has been linked to increasing prevalence.

Factors Associated With Increased Risk for Eating DisordersFemale genderDieting behaviorMiddle or upper-class socioeconomic

backgroundPersonality disorderFamily dysfunctionProfession or pursuit that stresses thinness

Careers: Ballet dancing, modeling, acting, certain sports

Diseases for which management involves emphasis on diet regulation

Diabetes and Cystic Fibrosis

Eating Disorders Objectives:

Discuss and understand the disorders associated with these eating behaviors

•Anorexia•Bulimia•Obesity•Eating Disorder NOS

Anorexia Nervosa Objectives

Epidemiology

Diagnostic Criteria

Medical Complicat

ions

Management

Epidemiology of Anorexia

Onset typically during adolescence More than three times as common in females Lifetime prevalence of .5 - 2% Subclinical variants occur in up to 10% of adolescent

females Psychiatric comorbidity

DSM-IV Diagnostic Criteria

Anorexia nervosa: Refusal to maintain body weight at or above minimally normal

weight for age and height Intense fear of gaining weight or becoming fat, even though

underweight. Disturbance in the way in which one’s body weight or shape is

experienced, undue influence of body weight or shape on self evaluation, or denial of the seriousness of current low body weight.

Secondary Amenorrhea Two types: restricting and binge eating/purging

Medical Complications of Anorexia Nervosa

Metabolic abnormalities Gastrointestinal and renal Cardiac and pulmonary Hematological and immunological Dental Fluid and electrolyte CNS and endocrine

Endocrine Changes in Anorexia Nervosa

• Impaired LHRH secretion leading to LH, FSH, and estradiol• Amenorrhea 2° hypogonadotropic hypogonadism• Delayed TSH response to TRH• Peripheral conversion of T4 T3 leading to normal T4 and low T3

levels• Conversion of T4 to r T3

• GH, cortisol, normal prolactin• Insulin and fasting glucose and abnormal glucose tolerance

Other Physiologic Changes in AN

Clinical hypothyroidism: dry skin, constipation, hypothermia, bradycardia, delayed deep tendon reflexes

Bradycardia & hypotension EKG changes: low voltage, prolonged QT interval, & S-T

segment depression Delayed gastric emptying and prolonged transit time

Medical and Nutritional Management of Anorexia Nervosa Multidisciplinary approach Weight restoration is a key goal Cognitive restructuring around food beliefs Hospitalization may be indicated if patient is <75% of

recommended weight-for-height

Pharmacologic Therapy for AN

Many medications have been tried in AN

including neuroleptics, appetite stimulants,

prokinetic agents, and antidepressants.

Most have little or no efficacy when compared to

placebo.

Serotonin-specific agents have shown promise

in patients after weight restoration. Prozac is

FDA approved.

Bulimia Nervosa Objectives

Epidemiology

Diagnostic Criteria

Medical Complicat

ions

Management

Epidemiology of Bulimia Nervosa

Term bulimarexia coined in 1976 Prevalence estimates of 4-9% of young women One study showed that 80% of college women have

binged Prevalence related to social weight norms Different theories of etiology

DSM-IV Diagnostic Criteria

Bulimia nervosa- Recurrent episodes of binge

eating characterized by: Eating in a discrete period

of time, an amount of food that is definitely larger than most people would eat during a similar period of time and circumstances.

A sense of lack of control over eating during the episode.

Recurrent inappropriate compensatory behavior in order to prevent weight gain.

Binge eating and inappropriate behavior both occur, on average, at at least 2/week X3 months.

Self evaluation is unduly influenced by body shape and weight.

The disturbance does not occur exclusively during episodes of AN.

Medical Complications of Bulemia Nervosa

Renal Gastrointestinal Electrolyte Laxative abuse complications Hematologic abnormalities Neurologic abnormalities Endocrine & dental abnormalities

Medical and Nutritional Management of Bulemia Nervosa Medical management to monitor electrolytes,

vital signs, and weight Pharmacotherapy with antidepressant

medication Nutrition education about body weight regulation

& consequences of bulemic behavior Cognitive-behavioral therapy to address

normalizing meal pattern and change attitudes and behaviors

Obesity Ojectives

Epidemiology

Diagnostic Criteria

Medical Complicat

ions

Management

Epidemiology of Obesity

If obesity is defined as the state of being 20% above ideal weight, then nearly a quarter of the U.S. population would be considered obese.

Socioeconomic status is highly correlated More common among women of low status Increasing age and obesity are associated until age 50

Diagnostic Criteria

Obesity is an excessive accumulation of body fat and operationally is defined as being overweight.

The BMI, which is weight (kg) divided by height (m2), has the highest correlation, 0.8 with body fat measured by other, more precise laboratory methods.

Mildly overweight-BMI 25-30 Obesity-BMI over 30 or body weight greater than 20%

above the upper limit for height.

Medical Complications

Obesity affects a great variety of physiological functions. Blood circulation may be overtaxed as body weight increases, and

congestive heart failure may occur in grossly obese individualsHypertension and hypercholesterolemia is strongly associated

with obesityIncreased body fat in the upper region of the body is more likely to

be associated with the onset of diabetes mellitus. Severe obesity may involve hypoventilation, hypercapnia,

hypoxia, and somnolence, Several types of cancers have been associated with obesity

Obese males associated with a higher rate of prostate and colorectal cancer Obese females have a higher rate of gallbladder, breast, cervical, endometrial,

uterine, and ovarian cancer.

Medical and Nutritional Management of ObesityTreatments: Mildly obesity: behavioral modification in groups, a

balanced diet, and exercise. Moderate obesity: a medically supervised protein-sparing

modified fast (400-700 calories per day) is often necessary.

Severe obesity: is most effectively treated with surgical procedures that reduce the size of the stomach. These procedures produce a substantial weight loss and show a good record of weight loss maintenance.

Cognitive Behavioral Therapy for Obesity

Behavioral modification is the treatment of choice for overweight children and adults.

Psychotherapy is not recommended as a treatment per se for obesity, although some patients may have particular problems that may be effectively treated or helped with psychotherapy.

Binge Eating Disorder Objectives

Diagnostic Criteria

Medical Complicat

ions

Management

DSM-IV Diagnostic Criteria

Eating disorders not otherwise specified (EDNOS)

For females, all of the criteria for AN are met except that the individual has regular menses.

All of the criteria for AN are met except that, despite significant weight loss, the individuals current weight is in the normal range.

All of the criteria for BN are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of <2/week or for a duration of <3months.

The regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food

Repeatedly chewing and spitting out, but not swallowing, large amounts of food.

Binge eating disorder: recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors characteristic of BN

Binge Eating Disorder

BED is a new diagnosis that refers to a pattern of recurrent binge eating episodes without the compensatory behaviors seen in bulemia.

Binge eating episodes are characterized by both large amounts of food consumed and feelings of loss of control.

Prevalence estimates in population studies are 0.5-2%. In patients seeking weight loss treatment it may be as high as 20%.

DSM-IV Diagnostic Criteria

Binge eating disorder (BED) Recurrent episodes of binge eating. The binge eating episodes are associated with 3 or more of the

following: eating much more rapidly than normal, eating until feeling uncomfortably full, eating large amount of food when not feeling hungry, eating alone because of being embarrassed by how much one is eating or feeling disgusted with oneself, depressed or very guilty after overeating.

Marked distress regarding binge eating is present The binge eating occurs, on average, at least 2/week X6 months The binge eating is not associated with the regular use of

inappropriate compensatory behaviors.

Medical and Nutritional Management of Binge Eating Disorder Primary Care Physician’s role is to identify patients and

assist them in seeking treatment. Patients may be reluctant to reveal their abnormal eating

pattern and may be unfamiliar with the fact that effective treatments exist.

Cognitive Behavioral Therapy for BED

Three Phases of Treatment: Phase 1 Treatment Initiation

Goals Educate r.e. BED Disrupt disordered eating patterns Regain control over eating Initiate exercise program

Tools Self-monitoring: foods, beverages, thoughts, feelings before

during & after eating, & binges Identification & practice of alternative behaviors Goals setting Stimulus control techniques

Cognitive Behavioral Therapy for BED

Phase 2 Cognitive Restructuring Goals

Identification and modification of maladaptive thoughts and beliefs Learn and practice problem-solving skills

Phase 3 Termination and Maintenance of Change Goals

Promote body acceptance Identify positive role models Encourage body enjoyment Decrease social avoidance

Develop a maintenance plan Anticipate future difficulties Identify high-risk situations Develop restart plan in case of relapse

What to Ask Patients

Do you eat regular meals and snacks during a typical day?

Do you feel distressed in any way about your eating pattern?

Do you ever feel that your eating is very chaotic or out of control?

Do you ever eat large quantities of food and feel that it is difficult to stop?

If yes, how often does this happen?

Follow-up Questions

Inquire about the nature of binge eating Do you ever eat large amounts of food even when not physically

hungry? Do you ever eat alone because of being embarrassed by how much

you are eating? Do you ever feel disgusted, depressed or very guilty after

overeating?

Inquire about compensatory behaviors Do you ever make yourself vomit or take laxatives? Do you use diet pills or any other diet aids?

Inquire about any prior treatment for eating problems and interest in current treatment

CBT for BED

Cognitive Behavioral Therapy Short-term, directed type of therapy Addresses behaviors and beliefs Uses self-monitoring “homework” Focuses on normalizing both eating behavior and dysfunctional

thoughts about food, shape, and weight

Treatment Issues in BED

Should weight loss be a goal of therapy Treatment modalities:

Physical activity Self-help Nutritional Counseling CBT Individual or Group Therapy Antidepressant

Quick Study ChartEtiology Diagnosis with Clinical

FeaturesCourse and Prognosis Treatment

Anorexia Nervosa-Restricting type-Binge eating/purging type

-Refusal to maintain 85% of normal weight for age and height-Intense fear of becoming fat-Disturbed body image-Amenorrhea-Physical findings include – lanugo, dry skin, emaciation, cold intolerance, hair loss, sunken eyes, bradycardia, hypotension, edema, hypothermia

-Complications – -CV – EKG changes, bradycardia, hypotension, CHF, MVP-Mild pancytopenia-GI – motility, LFTs-Renal – BUN, partial diabetes insipidus, stones-Osteoporosis-Endocrine – T3 and reverse T3

-No medication has out performed placebo-Various medications may help in adjunctive role if other mental illnesses or medical conditions exist-Success of psychotherapy depends on motivation-Family therapy-Brief hospitalization may be required for emaciated pt

Bulimia nervosa-Purging type-Non-purging type

-Recurrent episodes of binge eating-Fear of not being able to stop-Purging behavior-Over-concern with body shape and weight-Physical findings include – dizziness, hypotension, parotidomegaly, dental problems, abrasions of the knuckles

-Complications – -Fluid and electrolytes – K, Cl, dehydration, alkalosis-Dental – caries, enamel loss-GI – sore throat, Mallory-Weiss tears, parotidomegaly, cathartic colon, constipation

-Several antidepressants are superior to placebo for binge eating and purging-The SSRIs are 1st line of tx-Comorbid depression is not necessary for antidepressant effectiveness-Psychotherapy can be helpful for coexisting maladaptive attitudes and behaviors

Quick Study ChartEtiology Diagnosis with Clinical

FeaturesCourse and Prognosis Treatment

Eating disorder not otherwise specified -Binge eating disorder is included in this category

-Regular binge eating-Sense of lack of control during binge-Significant distress-No regular compensatory behavior

Obesity -Recurrent episodes of binge eating with the following characteristics – eating excessively more in one sitting than an non-bulimic and lack of control over stopping the binge or the amount of food consumed during the binge-Clinically – may include emotional basis of eating, binge eating, disparagement of body image, chew less and eat more rapidly, less active; BMI, hypercholesterolemia, HTN

-Causes estimated 300,000 preventable deaths/yr (2nd only to smoking)-Short-term weight loss has improved with diet and exercise strategies-Morbidity and mortality rates for obese pt in direct proportion to BMI-Don’t forget risk of DM type IIPrognosis is poor if left untreated

-Modest loss of 5-10% of body weight can control or improve complications-Emphasize weight management rather than weight loss-Diet, nutritional and exercise counseling, behavior therapy, drugs, and surgery (for pt with BMI>40 or those >35 with comorbid conditions like DM type II) are all options

Resources for More Information

American Anorexia Bulemia Assn., Inc. www.aabainc.org

Eating Disorders Awareness and Prevention, Inc. www.edap.org

National Eating Disorders Organization www.laureate.com/nedo/nedointro.asp

Overeaters Anonymous www.overeatersanonymous.org

Academy for Eating Disorders www.acadeatdis.org

Anorexia Nervosa & Related Eating Disorders, Inc. www.anred.com

Eating Disorders Quiz

Thank you for completing this moduleIf you have any questions, write to me:Tiffany.Bell@osumc.edu

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